Atypical presentation

1. ATYPICAL PRESENTATIONS
OF
DISEASESINTHEELDERLY

2. ATYPICAL PRESENTATIONS OF DISEASES IN THE
ELDERLY
.GENERAL(INTERNAL) MEDICINE UPDATE COURSE
• FACULTY OF INTERNAL MEDICINE
• NATIONAL POSTGRADUATE MEDICAL COLLEGE OF NIGERIA
• LECTURER: DR ALFRED E.A. JAIYESIMI : 26th July 2022

3. OUTLINE
➢ Definition and Demographic Implications of the
term Elderly
➢Ageing Process and Impact on Health
➢Ageing Vs Pathological Processes
➢Presentation of Diseases in the Elderly
➢Implications of Atypical Presentations of
Diseases in the Elderly

4. Definition and Demographic Implications of
the term Elderly
• The term ELDERLY is often used in a loose manner to imply persons advanced in chronologic years
in a community and is more of a socio-demographic classification
• As a chronologic phrase it refers to individuals who have attained the sixth decade of life and
beyond.
• As Western nations and highly developed countries –U.S.A; U.K; Israel; Japan e.t.c experience a
remarkable increase of Life Expectancy(average age at death) in a linear manner over the past
century and associated decrease in birth rate/fertility with improved childhood mortality rate the
population distribution pattern has shifted from a pyramidal pattern to squared or inverted
pyramid shape!
• A steady rise of life expectancy from 49 years for females and 45 years for males to about 84
years for females and 79 years for males presently occurs.
• Nigeria lacks accurate statistics of current population distribution but a cursory impression of
individuals attain the Sixth, Seventh and Eighth decades of life is not unusual.
• In Bangladesh life expectancy was 67.7 years in 2010 and 71.5 years in 2017. (Bangladesh Bureau
of Statistics)

5. WORLD-WIDE POPULATION ESTIMATES FOR THE ELDERLY AND
CLASSIFICATION
• ESTIMATES:
• YEAR Number(above 60 years old) World-population
• 2015 901 million 12.2%
• 2030 1402 million 16.5%
• 2050 2092 million 21.5%
• DEFINITION OF ELDERLY:
• Young Old : 60 to 69 years
• Middle Old: 70 to 79 years
• Old Old: 80 years and beyond
• (Forman D.E;Berman A.D;McCabe C.H;Baim D.S.;Wei J.Y; 1992 Journal of
the American Geriatrics Society. 40(1):19-22

6. Ageing Process and Impact on Health
• Whilst Elderly refers to chronologic years of life, it does not relate to
presence or absence of diseases, functional state and biological
changes that may be present in various organs such as the brain, skin,
cardiovascular system, kidneys, musculoskeletal system etc.
• Ageing is a biological process that occurs in all living organisms.
• Ageing process is not fully understood and appears to be
multifactorial and variable in rate of progression in various individuals
and in the different organs affected.
• The complex nature of ageing reflects the interplay of intrinsic
processes – genetic, metabolic, environmental factors; life style –
such as diet, sedentary, physically and intellectually active.

7. Ageing Process and Impact on Health (Contd)
In essence, it is not unusual to notice marked effects of ageing in some
sixty year olds and yet minimal ageing effects in Octogenerians.
• Furthermore, the ageing process may affect some organs more than
others and which organ is more affected varies from person to
person.
• The demographic changes resulting in an ever increasing prevalence
of an ageing population may be attributed to decreasing birth/fertility
rate; lowering of childhood mortality and improvements in medical
care and diagnostic facilities.
• It is vital to appreciate that individuals may neither age at the same
rate or in the same manner.

8. Ageing Process and Impact on Health (Contd)
• Likewise the Clinician is faced with the challenge of deciding the
effects of normal aging; pathologic changes and the cumulative effect
of pathologic conditions on a background of pre-existing aging effects.
• Whilst the effect of aging is a gradual decrement in function in various
organ systems, it is therefore possible for an elderly person to have a
resting level of performance to adequately cope with minimal daily
stress such as mobility, functions of daily living, intellectual activities
etc.
• The residual capacity of various organ systems may under stress
become grossly inadequate to compensate and cope physiologically
with a consequent marked disproportionate adverse effect.

9. Ageing Process and Impact on Health (Contd)
• In the elderly, normal homeostatic mechanisms may be blunted and
limited . An example is the poor Cardiovascular response of
tachycardia and increased cardiac output; decreased glomerular
filtration rate and renal blood flow; brain atrophy and degeneration of
neural cells leading to memory impairment, peripheral neuropathy
and autonomic disfunction.
• Diminished Lymphocyte proliferative response and Interleukin – 2 (IL-
2) production that occurs with aging is associated with decreased
immunity and increased susceptibility to infections and sepsis as well
as malignancies.

10. Ageing Vs Pathological Processes
• The multiorgan decrement in organ function and limited homeostatic
response to stress as well as concomitant co-existence of multiple diseases
results in atypical response and presentation to disease
• Metabolic dysfunction in the elderly may be sub-clinical i.e. a background
insensitivity of hormone receptors or decreased hormone production may
put them at risk of Diabetes Mellitus, Osteoporosis, Hypothyroidism which
may become pronounced due to environmental stress, infections or
medications.
• The elderly persons are also often exposed to social, financial limitations
and physical inabilities which may result in depression, social isolation,
poor nutrition, lack of confidence, limited mental stimulations as well as
loss of interest and limited mobility resulting in poor physical conditioning
i.e. muscle strength, coordination, poor gait and balance with increased
risk of falls.

11. Ageing Vs Pathological Processes
• The ‘empty nest’ i.e. all children far away from home or loss of a
spouse; retirement; physical limitation due to osteoarthritis; inability
to drive or read due to visual impairment and hearing loss may
aggravate cognitive decline and trigger fear, insomnia and depression.
• Poor visibility, muscular deconditioning, osteoarthritis with pain as
well as adverse effect of medication could lead to falls and fractures;
whilst fear of falls, loss of confidence walking with concomitant gait
and balance problems, pain relating to osteoarthritis could limit
mobility and result in urinary and fecal incontinence.

12. Ageing Vs Pathological Processes
• Cognitive decline as well as mood problems may also result in the
elderly failing to give accurate or detailed communication on how
they feel or the problems they are experiencing. It is therefore not
unusual that elderly persons may just complain of not feeling right or
being tired all the time.

13. Presentation of Diseases in the Elderly
• It is critical therefore that the Clinician appreciates the following:
❖Presentation of disease in the elderly may not conform to typical
textbook description of disease e.g. infection (chest, urinary, biliary)
may not present with fever, leucocytosis, productive cough,abdominal
pain or typical chest pain but rather may have hypothermia, loss of
appetite, acute confusion (delirium) or falls.
❖Likewise, infection may result in acute worsening of pre-existing
disease for example in breathlessness and heart failure; atrial
fibrillation, ventricular tachyrrhythmias or even myocardial infarction
without typical chest pain or sweaty episodes.

14. Presentation of Diseases in the Elderly (Contd)
Due to the haemodynamic effect of infection and sepsis – acute
cardiovascular events may be the initial presenting feature of sepsis.
Likewise the stress of sepsis in an elderly person may manifest with
overt Diabetes mellitus, acute confusional state, hallucinations, or
drowsiness
❖Assesment of the elderly must mandatorily consider and identify any
changes in baseline functioning, behaviour, cognitive state, mobility,
bowel or urinary habits as well as appetite and fluid intake. Any
sudden change or deterioration in any of these should be considered
an acute medical problem and may indicate some underlying disease
– acute or chronic

15. Presentation of Diseases in the Elderly (Contd)
❖The elderly have multiple disease conditions and may be on multiple
medications. Due to altered pharmacokinetics and increased adverse
effects in the elderly they may present with iatrogenic conditions
rather than underlying disease.
❖Misdiagnosis and missed diagnosis are commonly encountered in the
elderly and they are therefore either subjected to wrong treatment or
denied treatment. An example would be an agitated, delirious person
– due to sepsis, hyoxia, sedatives, stroke, heart failure or even
constipation being classified as dementia. Thus whilst delirium may
present with cognitive changes and altered level of consciousness it is
a reversible condition whilst Dementia is progressive and irreversible.

16. Presentation of Diseases in the Elderly (Contd)
❖Also, elderly person with Diabetes mellitus may not complain of
angina (chest pain) when they have an acute coronary syndrome (ACS)
or myocardial infarction i.e. silent MI but rather present with dyspoea,
confusion, nausea, fatigue or syncope. Elderly persons with Diabetes
mellitus or dementia or parasympathetic cardiac or peripheral
autonomic neuropathy are likely to have atypical presentation of
acute myocardial infarction and this could be as high as 40% of acute
MI in the elderly presenting in emergency service and result in denial
of appropriate therapy.

17. Presentation of Diseases in the Elderly (Contd)
❖Aging neurons in the elderly resulting in peripheral neuropathy and
autonomic neuropathy could result in decreased appreciation of sensations
– such as touch i.e. pain, joint position, temperature or, postural
hypotension; as well as bladder and anal sphincteric control. Neuropathic
ulcers, Charcot arthropathy – foot deformity, twisted ankle and
unsteady gait and balance could further impair mobility with muscle bulk
loss, loss of confidence walking, impaired gait and balance could result in a
chair-bound or bedbound lifestyle and associated massive leg swelling
(oedema) or decubitus i.e. pressure ulcers complicating the atrophic frail
skin. Associated urinary or fecal incontinence could except when full
cognitive assessment is done be deemed as features of dementia and lead
to placement in a nursing home rather than rehabilitative care

18. Presentation of Diseases in the Elderly (Contd)
❖Some clinical findings in the elderly may not indicate an underlying
disease. Examples of clinical findings in the elderly that may not be
significant are reduced skin turgor, fine crackles at the base of the lungs;
slightly reduced PaO2, neck stiffness, and a positive urine dipstick in
women (Bacteriua).
❖However, presence of red cells and protein in the urine dipstick should not
be dismissed. Likewise the presence of iron deficiency anaemia which may
present as fatigue or lethargy may be a red flag sign for underlying
malignancies in the gastro-intestinal or urinary tract.
❖Malignancies are common in elderly and may present in an atypical
manner such as anorexia, confusion, tiredness, leg swelling, deep vein
thrombosis, nephrotic syndrome or non specific anaemia. Aside of breast,
prostate and lung cancer, the elderly may develop multiple myeloma,
amyloidosis and gastrointestinal malignancies.

19. Implications of Atypical Presentations of Diseases
in the Elderly
❖Atypical presentation in the elderly person, of diseases may create
uncertainty if the initial attending physician lacks training and
experience.
❖Inappropriate investigations may be conducted, whilst simple
interventions such as rehydration, assessment of the skin for
abrasions, haematomas,and ulcers as well as cellulitis may be
overlooked.
❖Review of medications and possible drug-drug related interactions
are neglected
❖Malnourished state as well as electrolyte abnormalities such as
hypokalaemia, hypocalcaemeia or hypomagnesimia which may
coexist and easily treated may not receive attention.

20. Implications of Atypical presentations of
Diseases in the Elderly(Continued)
❖Delay in initiating appropriate management may lead to high
mortality and prolonged hospital stay.
❖Due to frailty, a tendency to withold or late treatment initiation may
occur in elderly with acute abdomen due to appendicitis, cholecystitis
or intestinal obstruction, or prostate cancer.